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STATE ID NUMBER 00000049766001 <br /> CONTAINER CONSTRUCTION <br /> E. I ) 01 RUBBER LINED ( ) 02 ALKYO LINING ( 1 03 EPDXY LINING f ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION [ 1 C4 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT [ ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ] 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( 1 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> f ] <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f J 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT RE^.U:RED TC COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( 1 <br /> 01 i l 02 f ) 03 <br /> ( l 01 i ) 02 ( ) 03 <br /> ( 1 01 f l 02 { ) 03 <br /> ( 1 01 ( 1 02 f 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> T ) 01 f l 02 f ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 i ) 02 { 1 03 <br /> { 1 01 ( 1 02 ( l 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINEP LCCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PEPSON PHONE W/AREA CODE <br /> D47E OF LAST ZNSPEC71ON IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT :D # <br /> ( l 01 YES i ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> 1 0 <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> B. I ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED f ] 02 SINGLE WALLED ( l 03 LINED <br /> D. (X) 01 CARBON STEEL ( 1 02 STAINLESS STEEL t l 03 FIBERGLASS f l 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( 1 G7 STEEL CLAD I ) 08 BRONZE { ) 09 COMPOSITE { ) 10 NON-METALLIC <br /> f ) 12 UNKNOWN ( ) 13 OTHER: <br /> PAGE 1 <br /> HSC04-070185 (10/18/85) <br />